Decontamination Manager

Detailed job description and main responsibilities

Act as the Senior Manager of Decontamination and be responsible for the delivery of critical Estates & Facilities (EFM) owned contract (Sterile Services, Endoscopy Decon, AED), ensuring contractors are delivering in accordance with contractual arrangements and providing value for money to the Trust.

-Be responsible for the delivery of high-quality services, which meet the standards, expected by EFM clients.

-Responsible to the Director of Estates and Facilities for the management of the contract (Sterile Services and Endoscopy Decontamination) and ensure that all elements are delivered in line with relevant HTM’s and statutory compliance.

-To implement and audit the operational teams to ensure appropriate governance is  being complied with.

-Ensure the contracts undergo rigorous service performance monitoring and that review arrangements that are in place to ensure that all remedial actions are identified and undertaken where necessary. 

-Work alongside the Capital team to ensure that all projects (especially in relation to Manage the interface between senior clinical leaders and the operational delivery teams.

-Lead on the development and implementation of excellent methodologies and practices to enable Estates and Facilities to adopt and practice a Quality Assurance Management regime for decontamination services. This will be based upon professional and technical excellence, sound protocols for Corporate Management including Risk Management in the delivery of quality healthcare.

-The post holder will be required to be fully conversant with and implement regional and national policies and initiatives, develop change, and manage an innovative approach to modernisation of the NHS.

-To oversee the Trust’s providers in partnership with Contract and Operational Management colleagues, to ensure close management of the contract to ensure that there is a programme in place for the service delivery and contract compliance of all services in line with Agreements and the relevant statutory compliance and quality standards.

-To manage and ensure internal compliance with the Trust's own contract management system.

-To act as Senior Manager with regards to compilation and demonstration of evidence to demonstrate Decontamination compliance with the Premises Assurance Matrix, (PAM)

-Responsible for the quality assurance of, monitoring and reporting of the effectiveness of Decontamination Services across the whole Trust, liaising with external bodies and working alongside peer Trusts to further enhance the level of Decontamination.

-Responsible for the introduction and maintenance of monitoring, audit, quality, and evaluation systems, ensuring that the agreed KPIs are met, and service delivery is within budgeted resources, within the Trust.

-Responsible for both on-going and long term (5-10 years) strategic policy development in relation to decontamination across the Trust as a whole, specific departments, such as Endoscopy or Theatres and 3rd party suppliers.

-Responsible for encouraging improvement in decontamination technology across the Trust, ensuring continuing development of and adoption of best practice, value for money and the development of policies for adoption by the Trust. Those policy areas may relate to Theatre Practice, Endoscopy, and Medical Physics etc. to provide staff with the necessary policies to decontaminate patients’ equipment safely from infection, injury or other harm whilst maintaining the integrity and purpose for each item of equipment was intended (external to the 3^rd party contract)

-Act as the Trust lead in all developments in Decontamination Technology, or Department of Health and other National (e.g. NICE/BSG/JAG/ISO) and European policy or guidance.

-Through management of Decontamination Services external to the 3^rd party contract, the post-holder is responsible for ensuring the continuous provision of specialist clinical technical services to theatres and wards and departments across the Trust. 

-The post-holder will inspect and be responsible for quality assurance by ensuring that all quality standards relevant to the Decontamination are met thereby ensuring that patients are not exposed to iatrogenic disease (i.e. resulting from the activity of the Trust) or cancelled procedures (external to the 3^rd party contract). 

-The post-holder will be expected to use their extensive knowledge and understanding of decontamination, clinical and technical processes as well as they’re in depth understanding of legislative requirements, to analyse any problems encountered and propose remedies and solutions to overcome these difficulties. When there are conflicting opinions, interpretations the post holder must use their extensive knowledge balance these demands against the need to ensure that ultimately the clinical safety of the patient is not undermined.

-To prepare reports to the Chair of the Decontamination Services Committee and the  Infection Prevention and Control Committee. The post holder will also be expected to provide executive reports to external bodies such as the Care Quality Commission (CQC) or the Medicines and Healthcare products Regulatory Authority (MHRA) and detailed technical specifications to contracting bodies for any new build or refurbishment schemes across the Trust.

-To develop internal procedures for correct testing and validation regimes of any relevant decontamination processing equipment external to SSD. And endoscopy Decontamination.

-To take responsibility for ensuring that all relevant processing equipment not covered by the 3^rd party contract within the Trust is compliant with the appropriate range of Health Technical Memoranda guidance and procedures, thus providing ‘best practice’ and minimising clinical risks to the Trust whilst providing patients with a quality service. 

-From a governance perspective to ensure that decontamination support reprocessing units provided by the third party are compliant. 

-To oversee the decontamination of re-usable medical devices external to SSD and Endoscopy Decontamination and ensure that efficient and effective processes are developed and followed in line with the relevant Trust policies and national guidelines.

-To perform the yearly audit to ensure reprocessing units are constantly delivering a service to JAG accredited standards.

-To provide expert advice and impart highly specialised knowledge to key

-Stakeholders including Infection Prevention & Control, Theatres, Medical Equipment, Endoscopy, and other service users on matters relating to decontamination, health technical memorandums, health building notes, new projects, and service provision.

-To liaise closely with key groups and service managers and users, e.g. Medical Devices, Risk Management, Theatres, Wards, and Clinics to ensure an adequate and reliable service is provided by the contracted service and is reactive to change. The post holder will have the authority and freedom to initiate and develop practice within a Clinical Governance framework.

-To create and deliver appropriate training packages in relation to decontamination in clinics to relevant staff groups across the Trust as necessary, ensuring that all personnel within the departments are appropriately trained and competent to undertake a full range of duties associated with their role and are able to meet quality objectives and perform their duties safely and effectively at all times.  

-To be responsible for the implementation and monitoring of a Trust wide audit programme which benchmarks services against current standards relating to decontamination. The postholder will support areas to develop actions plans relating to audit findings and help monitor their completion.

-To undertake performance data analysis and share finding at the Decontamination Committee with appropriate recommendations.

-To lead in the development and implementation of the decontamination section of the Trust Infection Prevention & Control Annual Plan reflecting the Trust’s objectives to minimise avoidable healthcare associated infections, taking responsibility for specific areas, and leading on these.

Savings Efficiency and Commercial Opportunities  

-To lead the formation of updated service specifications in preparation for Sterile Services, Endoscopy Decontamination and AE(D) contracts tendering or re-tendering as appropriate, to reflect the present and future requirements of the Trust.

-To support development of strategies for the Trust regarding future service delivery models, including consideration for Market Testing processes where required.

-To comply with standing financial instructions, business planning arrangements and Trust policies to ensure the highest level of probity in all financial matters.

-Awareness of relevant information related to Performance policies and service deliverables and contracts; data set changes and communicates issues to a wide audience.